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Exposure Strategies for PTSD Treatment

Although Posttraumatic Stress Disorder (PTSD) was originally codified in the DSM-III as an anxiety disorder, clinicians working with survivors know that the shame and guilt experienced by these clients are some of the most toxic and difficult emotions to work with. While it can be expected that following a horrifying trauma a survivor would experience terror, the shame or guilt associated with self-blame for the event entangles the mind.

In a recent study, Langkaas and colleagues (2017) hypothesized that in individuals with PTSD, the presence of these non-fear-based emotions would interfere with and predict poor response to exposure therapy for PTSD. These researchers compared exposure procedures with imagery rescripting, a procedure believed to be better suited for non-fear-based emotions. In exposure, the individual repeatedly and for a prolonged period revisits the trauma memory using imagery. In imagery rescripting, the individual revisits the trauma memory but rewrites the ending of the traumatic event by having the present version of the survivor enter the memory and correct his perceived culpability in the traumatic event. None of the hypotheses were supported. Exposure strategies were just as effective as imagery rescripting. The same level of impact on fear and non-fear emotions was observed. How could that be?  How could exposure help emotions like shame and guilt?

Cognitive Formulation of PTSD

PTSD can be thought of as a phobia to a memory that develops after a traumatic event. As a result, the individual avoids:

  1. the memory itself (thought suppression), and
  2. reminders or cues of the memory (internal or external).

When an individual avoids a memory, any attempt to review, organize, or recall details are halted. The memory becomes unavailable for the individual to gather meaningful information for the purposes of cognitive restructuring.

Emotions like shame and guilt are nourished by thoughts attributing responsibility, culpability, and agency to the individual.

  • In guilt, the individual believes he should have acted differently (e.g., said “No,” stopped the massacre, avoided the party).
  • In shame, the individual asserts that he should have physically reacted differently (not frozen, not had a sexual reaction, not given up) and that something unique to him brought about the trauma. (For example, he might have the thought, “I should have been able to stop the trauma,” or “The perpetrator chose me because I was different.”)
Strategy for Change: Exposure

To reduce or eliminate the experiences of non-fear emotions, such as shame and guilt, the individual needs to correct these unhelpful and inaccurate cognitions. The difficulty with using a Socratic approach to testing the cognitions is the inaccessibility of corrective data or evidence. For example, a man traumatized as a young child harbors the belief “I should have stopped the perpetrator.” This belief leads to guilt for not stopping the trauma that occurred. For years, family, friends, and professionals told him that it wasn’t his fault; he was a little boy. However, these kinds of words never led to meaningful relief and often led to further guilt.

To gain lasting relief, the man needs to consider the basic Socratic questions, “What is the evidence that it was your fault? What is the evidence it was not your fault?” The confounding factor in PTSD is that the evidence needed to correct the belief is found through deliberately considering the events of the trauma–the same memory the individual phobicly avoids. Further, meaningful correction of a belief requires extended review of this evidence and the ability to process the information. Logical thinking is paralyzed during extreme anxiety and the individual relies on avoidance as a coping strategy. Avoidance of the memory explains why the man does not come to the most logical conclusions: He was just a boy and had no power in the moment.  Because he avoids the memory, he has no evidence on which to develop a new conclusion.

The memory elicits such intense anxiety that the individual cannot systematically review and integrate data from the event. As long as the individual has the phobic reaction to the memory, correcting the belief will be difficult. Therefore, exposure can be a straightforward and efficient strategy for resolving PTSD symptoms and non-fear-based emotions.

Exposure Strategies
  • Habituation to the trauma memory allows for organization of the memory and extended time for reviewing the details of the event.
  • The extended time reviewing the memory, for the purposes of habituation, provides the individual exposure to the corrective information. In some cases, individuals return after the second or third exposure to the trauma memory and tell the therapist, “I was only five; there was nothing I could do!”

Without the phobic reaction to the memory, the individual can look at the cognitions associated with shame and guilt and correct them with the available evidence. In cases where the shame and guilt cognitions do not correct through the repetition of the memory alone, the therapist can draw the individual’s attention to the newly available data or ask well placed questions to correct the unhelpful and inaccurate belief.

Posttraumatic Stress Disorder brings chaos into a survivor’s life. A clinician can easily feel overwhelmed and confused by a survivor’s presentation, which is often complicated by shame and guilt. This reaction to the complexities of PTSD can lead the clinician to make unhelpful hypotheses and interventions. With an individualized cognitive formulation, the clinician can make sense of the chaos and collaboratively select a coherent, long-term strategy for change.

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CBT for PTSD

The post Exposure Strategies for PTSD Treatment appeared first on Beck Institute for Cognitive Behavior Therapy.

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April 2018
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Two-day CBT for Chronic Pain workshop taught by Dr. Christina Shook for Clackamas County Health Centers in Oregon City, OR.

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Therapeutic Drift

How to Maintain Therapeutic Effectiveness

Many studies have demonstrated that work performance level for a variety of professions decreases in effectiveness over time. Specific activities are often mandated to help individual practitioners maintain skills at a high level. For example, practicing radiologists are required to review films and compare their readings to what was actually found to be wrong with a patient. Practicing psychotherapists have mandated educational requirements (for example, continuing education credits for maintaining licensure or board certification). However, such activities seldom, if ever, entail any focused practice or measurement of therapeutic skills. Even mandated peer review of patient records generally involves a review of documentation and treatment planning rather than an actual measurement of what occurs within a therapy session. Since we know that experienced professionals often stop improving and experience deterioration of their skills over time, this practice is short-sighted.

Recently, research has shown significant consequences of so-called “therapeutic drift” (Waller & Turner, 2016). The drop-off in skill levels of therapists, the variable use of empirically supported treatments, especially behavioral interventions in therapy, and the faulty implementation of such treatments potentially lead to further patient suffering and the public perception of ineffectiveness of our treatments. Compounding the problem of drift is biased thinking common to all therapists. Therapists’ misattributions about their own skill levels are significant. Walfish et al (2012) found in a multidisciplinary practitioner survey that not one therapist viewed him or herself as below average and that 25% of the respondents said they were in the top 10% of all therapists. Additionally, they rated the vast majority of their patients as improved, contrary to what we know about average rates of patient improvement.

So how do we overcome drift? Here are three steps every therapist can take to increase adherence and effectiveness.

First, measure patient outcomes. Lambert et al (2005) has demonstrated the value of regular outcome monitoring in a series of studies. Obtaining frequent ratings of patient symptoms using a validated instrument is critical to determine how therapy is progressing, since, as noted, clinicians are unable to accurately discern how patients are progressing. In addition, sharing the ratings with patients increases the value of such monitoring, as it creates a context to have a conversation about lack of progress and may potentially increase patient commitment.

Second, practice automatic sequences that you employ in therapy. This can involve observing carefully the micro-skills of therapy and systematically evaluating how effectively you perform. For example, agenda setting, homework assignments, automatic thought records, and obtaining and responding to feedback can be deployed and practiced in rotation with observation of patient responsiveness and evaluation of your efforts. This will increase the accuracy with which you employ the skill and decrease therapy “autopilot.” Without such deliberate practice you will fail to see how you can improve.

Third, listen to and rate therapy recordings with a validated instrument like the Cognitive Therapy Rating Scale. Even better, have an agreement with a like-minded therapist friend to share recordings and rate one another’s tapes. Chow and his colleagues (2015), in an interesting new article, linked deliberate practice activities to superior therapy outcomes. One observation they made was that therapists who spent time listening to recordings made an enormous difference in how well patients did. Cognitive-behavioral therapists can use the CTRS to evaluate the quality of their sessions, improve their performance, and consequently their patient outcomes.

References

Chow, D.L., Miller, S.C., Seidel, J.A., Kane, R.T., Thornton, J.A., Andrews, W.P. (2015) The Role of Deliberate Practice in the Development of Highly Effective Therapists. Psychotherapy, 52 (3), 337-345.

Goldberg, S. B., Rousmaniere, T., Miller, S. D., Whipple, J., Nielsen, S. L., Hoyt, W. T., & Wampold, B. E. (2016). Do psychotherapists improve with time and experience? A longitudinal analysis of outcomes in a clinical setting. Journal of counseling psychology, 63(1), 1-11.

Lambert, M. J., Harmon, D., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61, 165–174.

Walfish, S., McAlister, B., O’donnell, P., & Lambert, M. J. (2012). An investigation of self-assessment bias in mental health providers. Psychological Reports, 110(2), 639-644.

Waller, G., & Turner, H. (2016). Therapist drift redux: Why well-meaning clinicians fail to deliver evidence-based therapy, and how to get back on track. Behaviour research and therapy, 77, 129-137.

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Teaching and Supervising CBT

June 25-27, 2018


The post Therapeutic Drift: How to Maintain Therapeutic Effectiveness appeared first on Beck Institute for Cognitive Behavior Therapy.

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The Diabetes Problems We Aren’t Talking About

CBT for Medical Conditions

In 2014, the diabetes education and advocacy nonprofit, diaTribe, surveyed over 7,400 people about the psychological toll of living with diabetes. They found that approximately 65% of people living with type 1 diabetes, and 50% of people living with type 2 diabetes believe that this condition negatively affects their self-confidence and their ability to take on life’s challenges. Contributing factors include misconceptions about the causes of diabetes, and what is required to manage the disease.

Many people living with diabetes believe that this condition negatively affects their self-confidence and their ability to take on life’s challenges.

Many people believe that those living with diabetes brought it on themselves by poor diet and lack of exercise. Often, newly diagnosed individuals harbor these beliefs about themselves. This is especially true for type 2 diabetes. With type 1 diabetes, the body suddenly and unexpectedly stops producing insulin. However, with type 2 diabetes, the body produces insulin, but the cells have trouble using it. When patients believe that the development of a disease is their fault, they are likely to experience guilt and shame, which can lead them to avoid the support and regimen they need to manage the disease. This can ultimately lead to sub-optimal medical and self-care.

Our patients with diabetes have a great deal to manage with this complex and difficult condition. They must consider the types and quantities of food they eat, the timing of meals and snacks. They must also manage blood glucose levels which may spike or drop without warning, all amidst an expectation of precision. These are the challenges we know about. There are, however, other problems that require our attention. Often overlooked are the feelings of failure and shame experienced by individuals living with diabetes.

Often overlooked are the feelings of failure and shame experienced by individuals living with diabetes.

Over the past two decades, research focused on the psychosocial aspects of management of the disease has suggested that diabetes-related stigma has negative consequences for psychological well-being and self-care, affecting clinical outcomes (Schabert, Browne, Mosely, & Speight, 2013). It is widely understood that changes in diet and exercise are difficult to achieve.

Diabetes-related stigma has negative consequences for psychological well-being and self-care, affecting clinical outcomes.

We have learned from the obesity research that individuals find it challenging to lose and maintain even modest amounts of weight. For some people with diabetes, the failure to follow suggested lifestyle changes results from their reluctance to be viewed as different in the eyes of their peers. Barriers to treatment for adolescents are often related to social situations and environmental influences, embarrassment, and seeking acceptance or perceived normalcy (Mulvaney, et al., 2008). Individuals with diabetes across the lifespan struggle with making food choices that support their needs.

Consider this patient example: Anna, a first-year college student with type 1 diabetes, managed her blood sugar reasonably well throughout middle school and high school–in large part due to family structure and parental support. However, when she went away to college and was left to make her own decisions, she was unprepared to navigate certain social situations. Particularly difficult were the late-night study breaks in which her friends had pizzas delivered when her blood glucose levels were elevated, or outings where stopping to take her blood sugar and give herself insulin left her feeling different. She found herself eating whatever her friends were eating, or giving herself insulin late, so she wouldn’t feel “different.” Anna became ashamed of her condition.

The key to working with Anna was first to understand the core beliefs that got triggered when she was faced with the difficult choices of taking care of her chronic disease or fitting in to the social milieu. Next, we worked to empower her to take ownership of her disease and treat herself the way she would treat someone she loved with the same chronic illness.

References

DiaTribe

Mulvaney, S. A., Mudasiru, E., Schlundt, D. G., Baughman, C. L., VanderWoude, A., Russell, W.E., Rothman, R. (2008). Self-management in type 2 diabetes: the adolescent perspective. Diabetes Educator, 34 (4): 674-82. doi:10.1177/0145721708320902.

Schabert, J., Browne, J. L., Mosely, K., & Speight, J. (2013). Social stigma in diabetes: A framework to understand a growing problem for an increasing epidemic. Patient, 6:1-10. Doi:10.1007/s40271-012-00001-0

Upcoming Workshop


CBT for Medical Conditions

May 14, 2018


The post The Diabetes Problems We Aren’t Talking About appeared first on Beck Institute for Cognitive Behavior Therapy.

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New Breakthroughs in Cognitive Therapy: Applications to the Severely Mentally Ill (Part 3)

Aaron T. Beck, MD
Note: This article summarizes Aaron Beck’s interview with Judith Beck at the Evolution of Psychotherapy Conference in Anaheim, CA, December 16, 2017, for which he received a standing ovation from over 7,000 conference participants.

Read Part 1 and Part 2.

A Case Illustration

When we work with individuals with schizophrenia who have been hospitalized for many years, we need to find out what their needs are. We are often able to draw on their delusions. For example, six inpatients had delusions that they were God or Jesus. In our attempts to find out what the delusions could tell us about the individuals’ needs, we asked the question, “What is good about being God?” We got a number of answers which then provided very strong clues regarding the individuals’ aspirations and needs.

To our surprise, several of the individuals responded to the question, “What is good about being God?” by saying, “You can help people.” This gave us the beginning of the pathway to a formulation and action plan. One of the individuals responded that if he were God, he would live forever. This pointed to the individual’s fear that he was suffering from a fatal disease and that he would die soon. Thus, living forever was protection from dying. Another individual replied, “I can control heaven and earth and all the planets.” This led to a discussion about the individual’s feeling that he had no control over his life. His delusion served a purpose: to compensate for lack of control. His action plan was to start a library on the unit. This gave him control over the books and some sense of control over the borrowers of the books, since they were obligated to return the books at a specific time, and the individual would remind them of this. The delusions served as a compensation for feelings of being insignificant, devalued, and helpless, thus providing a link to a treatment plan.

We also found that bizarre behavior and beliefs provided information we could use to formulate our treatment plan. A man in a structured residence would ask the male attendants to inseminate him. Although at first this was a source of amusement to the staff, they eventually simply ignored him. As a result, he became more persistent. Our therapist made contact with him, and after establishing a connection, the patient asked, “Would you inseminate me?” The therapist then asked our standard question, “What would be good about being inseminated?” The individual responded that he would then have a baby or a number of babies. In response to a question regarding the value of having a baby, the man said that he would feel important, have someone to take a care of, and have a friend. Next, the therapist asked, “When you think of being important or having a friend, what feelings do you get?” The individual responded by saying, “I feel good, secure, and comfortable.” The therapist then asked, “Do you recall ever feeling this way before?” The individual replied, “I once had a dog named Rex. We were great friends. I took good care of him, went for walks, I cleaned him up when I needed to, and in general we were very close. When I came home from school, he would start to bark and greet me at the door.”

The idea of having a dog transformed the clinical approach to this individual. The members of the staff started to collect pictures of dogs from calendars and other illustrations and pasted them on the wall. As the individual became more involved with animals, he started to talk about making this his career. Incidentally, he stopped talking about being inseminated. In less than a year, he began making a few trips to an animal shelter. Then he was ready to be discharged and indeed did get a position at an animal hospital. Interestingly, he eventually made friends with the other personnel. The point of all this is that by satisfying a basic need, the individual was able to progress into more realistic planning and thinking.

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New Breakthroughs in Cognitive Therapy: Applications to the Severely Mentally Ill (Part 2)

Aaron T. Beck, MD
Note: This article summarizes Aaron Beck’s interview with Judith Beck at the Evolution of Psychotherapy Conference in Anaheim, CA, December 16, 2017, for which he received a standing ovation from over 7,000 conference participants.

Read Part 1.

Incorporating Key Strategies from the Recovery Movement

While we were developing our treatment protocol for individuals with schizophrenia, we became aware of the recovery movement and formulated a new therapy incorporating the recovery objectives. We systematically operationalized a set of strategies to attain these objectives. Although our initial work was with an outpatient population, I posited that if this therapy were truly effective, then it should work on the most severally mentally ill. We established a contract with the state hospital and started to supervise the treatment of patients with severe mental illness. The steps that we followed with these long-term inpatients were:

  1. Establishing contact: Many of these patients were not readily approachable. One individual sat in the corner with a blanket over his head. Another stayed in his room all day and would not leave. The third sat in a chair hallucinating all day. One of our therapists was able to establish contact with the first individual by approaching him and asking whether he could recognize music she was playing from her phone. She continued to visit him, and during each visit he responded more readily to the music. After a week, he was aroused sufficiently to join some of the other patients who were either playing the piano or singing and dancing.
  2. Engagement: The next step was forming a close bond with the patient, which we call engagement. The engagement phase consisted of several elements. One was the importance of equalizing the relationship. Our staff member would collaborate with the patients on activities that were both pleasurable and meaningful to them, including playing games, asking for the patients’ advice, or going to the gym together. In one case, a staff member and a patient collaborated by building a birdhouse together. The next step was to elicit the individual’s aims, goals, and aspirations and so on. We did this through guided discovery, determining talents, strengths, past positive experiences, successes, etc.
  3. Formulation and Action Plan: The action plan provided a pathway to the individual’s aspirations, culminating in the individual’s feeling more efficacious, valued, and socially desirable. The objectives often involved regaining contact with family and friends, making new friends, going out on a date, or getting involved in meaningful jobs. The individual was likely to encounter many obstacles along the way, including psychotic symptoms, discouragement, and poor problem-solving. Staff would work together with the individual to address each of these problems as they arose. Indeed, many of these problems seemed to resolve as the individual returned to a state of increased wellbeing, including poor problem-solving, poor interpersonal relations, and overreaction to frustration.

Part 3 coming next week.

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February 2018
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February Training for Organizations

One-day Essentials of CBT for Youth workshop taught by Dr. Michael Tompkins for Laramie County School District in Cheyenne, WY.

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New Breakthroughs in Cognitive Therapy: Applications to the Severely Mentally Ill (Part 1)

Aaron T. Beck, MD
Note: This article summarizes Aaron Beck’s interview with Judith Beck at the Evolution of Psychotherapy Conference in Anaheim, CA, December 16, 2017, for which he received a standing ovation from over 7,000 conference participants.

Origins and Development of the Treatment

Early in my career, I treated a delusional patient who believed he was being followed by government agents. This individual recovered, and I was enthusiastic about using psychotherapy to treat individuals suffering from delusions. Many decades later, I supervised a resident who was treating an individual with delusions at one of the hospitals. This individual believed that all the other individuals in the unit were members of the Camden police force. At my urging, the resident suggested she get to know each of the people on the unit closely, and be able to describe them. Over the course of time, the number of supposed police gradually diminished to zero. At the time, I attributed her improvement to increased focus. Later, I realized that forming social relationships with the other members of her unit also played a key role.

Sometime later, I discovered that several British groups were successfully treating individuals with schizophrenia using CBT. They adapted various CBT strategies to address the unique needs of this patient population. This inspired me to see if we could develop a treatment based on the principles of cognitive therapy that could address the negative symptoms of schizophrenia. Paul Grant and I (Grant & Beck, 2009) developed several questionnaires and determined that the negative symptoms, namely isolation, were related to defeatist beliefs such as, “If I try something, I will only fail” and asocial beliefs such as, “If I reach out to people, I will only be rejected.” We found that this formulation correlated significantly with the negative symptoms of schizophrenia and indeed our findings were replicated by almost a dozen other investigators. Following our discovery, we conducted a randomized control trial in which we adapted CT to this patient population (Grant et al, 2017).

Part 2 coming next week.

References:

Paul M. Grant, Aaron T. Beck; Defeatist Beliefs as a Mediator of Cognitive Impairment, Negative Symptoms, and Functioning in Schizophrenia, Schizophrenia Bulletin, Volume 35, Issue 4, 1 July 2009, Pages 798–806, https://doi.org/10.1093/schbul/sbn008

Six-Month Follow-Up of Recovery-Oriented Cognitive Therapy for Low-Functioning Individuals with Schizophrenia. Paul M. Grant, Keith Bredemeier, and Aaron T. Beck. Psychiatric Services 2017, 68:10, 997-1002

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Cory Newman, Ph.D.

CBT provides a powerful set of interventions for the treatment of patients suffering from substance use disorders (Beck, Wright, Newman, & Liese, 1993; Newman, 2008), and works in a complementary fashion with 12-step approaches that provide patients with valuable social support and a methodology for change (Ouimette, Finney, & Moos, 1997). At times our patients pose questions about the compatibility of lessons they learn in their 12-step meetings with the principles of self-help they are learning in CBT. While it is important to acknowledge that there are differences between the two approaches, these differences can be bridged so that patients can avail themselves of both sets of methods without an undue sense of confusion or conflict.

The Concept of “Powerlessness”

In 12-step philosophy, persons must admit that they are “powerless” in the face of their addictions, and that their lives have become unmanageable. Patients sometimes ask us, “How can I take part in CBT self-help if I have to admit to being powerless?” Our answer is that the “powerlessness” which they are acknowledging has to do with their prior behavioral and cognitive habits that were maintaining their problems with substances. Indeed, when patients are actively involved in using their chemical(s) of choice, it is folly for them to continue to enact the same behavioral habits and to manifest the same problematic beliefs and yet expect to recover, and/or to have their lives improve. By utilizing CBT self-help skills, patients are trying something new that gives them a chance at positive change, whereas reverting to old patterns will disempower them and make their lives less manageable.

Absolute Abstinence Versus “Harm Reduction”

Patients sometimes enter therapy in a “stage of change” (see Prochaska & Norcross, 2002) in which they do not wish to become abstinent from drinking or using other psychoactive drugs. Instead, they profess to wish to reduce or “control” their drinking and/or using, but not to discontinue altogether. They may avoid 12-step meetings based on the expectation that they can attend only if they agree to an absolute cessation of drinking or using. Such patients may view CBT as a more user-friendly venue, especially if they have read about the concept of “harm reduction” (e.g., Roberts & Marlatt, 1999). These patients may jump to the conclusion that “a little bit” of drinking and/or using is “allowed” in CBT. In response to this assumption, we as CBT practitioners can make it clear that while we generally eschew “all-or-none” thinking, and while we believe it is better to make improvements in stages (via the behavioral concept of “shaping”) rather than make no changes at all, we also recognize that abstinence is indeed the safest outcome. Nevertheless, gaining “admittance” into outpatient CBT typically is not contingent upon a commitment to total abstinence, as it is important for practitioners to positively reinforce any attempts by patients to take part in treatment. Further, it is our intention that by teaching patients skills such as self-monitoring, tolerating unpleasant emotions, minimizing exposure to high-risk situations, postponing acting on cravings, and modifying addiction-related beliefs, they will gradually move closer to the goal of abstinence (something which may never happen if we insist on abstinence from the start).

We also do not want our patients to respond to a lapse by believing that this is as bad as a full relapse, lest they conclude erroneously that they “might as well relapse all the way” by drinking and using as much as they want (now that they’ve broken their abstinence). An important part of utilizing CBT is recognizing how to “nip a lapse in the bud” by re-doubling efforts to apply self-help skills, reaching out for social support, contacting the therapist to schedule a CBT appointment as soon as possible, and perhaps going to a 12-step meeting. For good measure, CBT therapists point out the all-or-none thinking that patients engage in when they state that they cannot go to a 12-step meeting if they are drinking or using. Not infrequently, 12-step groups will accept such participants, provided that they are honest in their self-disclosures and show genuine motivation to “work the steps.”

Is Pharmacotherapy for a Comorbid Disorder Just Another “Chemical Dependency?”

The treatment of comorbid substance use disorders with other psychiatric disorders (e.g., unipolar depression, bipolar disorder) often includes appropriate pharmacotherapy. Unfortunately, some patients misconstrue taking medications (such as mood stabilizers) as being synonymous with chemical dependency. In response, CBT therapists provide psycho-education, explaining that while some medications (such as anxiolytics) that are quick-acting, have a short half-life, and can induce an immediately noticeable “altered state” are often contraindicated in patients with chemical addictions, there are other medications that do not pose such a risk. Slow-acting medications (e.g., anti-depressants, mood stabilizers, anti-psychotic medications) that do not create a “buzz” do not pose a risk to the person with substance use disorders. We add that a clinically significant “chemical dependency” refers to the habitual use of chemical(s) that impair the user’s ability to function well in their life roles as family member, friend, student, employee, employer, and citizen. By contrast, taking a properly prescribed and monitored medication that improves and sustains a person’s ability to function well in their important life roles is not a problematic chemical dependency to be avoided. To be fair, it seems that most people who take part in 12-step groups see it this way, too.

“Stinking Thinking!”

This is one area where CBT and 12-step principles agree entirely. A person’s thinking style is a very important part of their overall psychological functioning and recovery goals. The ability to look at oneself and one’s life with greater objectivity, openness to new facts, and a systematic (non-impulsive) process is central to making good decisions, improving self-efficacy, and maximizing healthy, favorable outcomes. Participants in both CBT and 12-step groups (as well as their therapists and sponsors) watch out for such faulty thinking as:

  • Permission-giving beliefs: Also known as “rationalizations,” these are beliefs in which people spuriously justify their drinking and/or using. An example is, “I haven’t used cocaine for three months, so I think I’ve earned the right to use this weekend.”
  • Magnification of craving: Here, people who are considering or trying to be abstinent dwell on the idea that their cravings will continue to increase unabated until they either “go nuts” or give in and use. They do not consider a third option – that the cravings are manageable and will naturally subside — and they will neither “go nuts” nor necessarily have to use.
  • Apparently irrelevant decisions: This type of thinking pertains to how people set themselves up for lapses and relapses by unnecessarily choosing to put themselves in vulnerable positions, “reasoning” to themselves that they didn’t see the harm. An example is a person in recovery who drives his friend to a bar (“just to drop him off”) rather than explain (to himself and the friend) that this would be too risky to his own sobriety.
  • Hopelessness: This kind of thinking is dangerous to a person’s sobriety, and perhaps to his or her life as well. Hopelessness invites someone to give up, to stop all attempts at coping, and to “not care” what happens. It runs completely counter to “working a program.”
Conclusion

Therapists providing CBT to their patients with substance misuse problems can support the patients’ involvement in 12-steps groups without having to be concerned that the two approaches are incompatible. When patients demonstrate sufficient motivation to take part in both individual CBT and group 12-step meetings, it is important to support them, while at the same time being ready to explain some of the apparent differences in the tenets of the two approaches. Some straightforward reframing (as described above) is typically enough to reduce confusion, and in some areas (e.g., “stinking thinking”) the points of convergence speak for themselves.

Learn more at our CBT for Substance Use Disorders workshop.

References

Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse. New York: Guilford Press.

Newman, C. F. (2008). Substance abuse. In M. A. Whisman (Ed.), Adapting cognitive therapy for depression (pp. 233-254). New York: Guilford Press.

Ouimette, P. C., Finney, J. W., & Moos, R. H. (1997). Twelve-Step and cognitive-behavioral treatment for substance abuse: A comparison of treatment

effectiveness. Journal of Consulting and Clinical Psychology, 65, 230-240.

Prochaska, J. O., & Norcross, J. C. (2002). Stages of change. In J. C. Norcross (Ed.), Psychotherapy relationships that work (pp. 303-313). New York: Oxford University Press.

Roberts, L. J., & Marlatt, G. A. (1999). Harm reduction. In P.J. Ott, R.E. Tarter, & Ammerman,   R.T. (Eds.), Sourcebook on substance abuse: Etiology, epidemiology, assessment, and             treatment (pp. 389-398). Needham Heights, MA: Allyn & Bacon.

The post Reconciling 12-Step Tenets with Principles of CBT for Substance Use Disorders appeared first on Beck Institute for Cognitive Behavior Therapy.

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Robert Hindman, PhD

Depressed clients often isolate themselves from others and withdraw from life. A depressed client of mine I’ll call Adam did exactly this. He began feeling depressed after his marriage ended. He stopped responding to calls and social invitations from friends and family members. He also stopped going to the gym and gave up his favorite hobby, golfing. When clients withdraw from life, they give up any chance of meaningful or pleasurable experiences, so their depression is more likely to continue and become more intense.

To counter the isolation and withdrawal common to depression, therapists can introduce behavioral activation. This strategy entails getting clients more active and involved in life by scheduling activities that have the potential to improve their mood. Research suggests that behavioral activation alone is an evidence-based treatment for depression, and may be particularly well-suited for chronically depressed clients (Sturmey, 2009). The following tip from the Beck Institute therapists can help make behavioral activation even more effective.

It’s important to focus on valued or meaningful activities instead of, or in addition to pleasurable activities as part of behavioral activation. Many depressed clients (especially those with chronic or severe depression) state that there aren’t any activities that give them a sense of pleasure. They may also come to the following session feeling frustrated and hopeless because they didn’t enjoy the activities as much as they had before they became depressed, or they didn’t enjoy them at all. While emotions and moods are temporary, values tend to be more stable and can serve as a guide for behavioral activation. We can obtain the client’s values by listing different value categories and then asking the client to rate the strength of each category from 0 (not valuing it at all) to 10 (the most they can value something). The categories we include are work, self-education/learning, volunteering, intimacy, family, friendship, religion/spirituality, entertainment/recreation, and health/fitness. Adam’s most valued categories were friendship (10), family (9), recreation/entertainment (8), and health/fitness (8).

The client’s value ratings indicate the best place to begin with behavioral activation. Start with the highest value rating, which, for Adam, was friendship. We ask our clients, “Why is [the value] important to you?” Adam responded that friendship was important to him because it provided mutual support and shared experiences. We then ask the client to list specific, concrete activities that make up the value category. For friendship, Adam’s list of activities included: poker night, golfing, watching sports together, going out to dinner, and regular phone calls. We then repeat these steps for the remaining high value categories. Typically, we won’t ask about a category if the client rated it below a 5 out of 10.

Finally, we help the client decide which valued activities to engage in. Instead of telling the client what to do, we collaboratively ask the client which activities they want to schedule. In his friendship category, Adam decided to call his friend, Matt, to inform him that he would be attending their weekly poker night on Wednesday. During poker night, Adam decided to seek support from his friends by talking about having a difficult time after his divorce and making additional plans for the weekend with whoever was available. He agreed to suggest they play a round of golf on Sunday.

References

Sturmey, P. (2009). Behavioral activation is an evidence-based treatment for depression. Behavior Modification, 33, 818-829.

Learn more about treating depression at the CBT for Depression and Suicide workshop.

The post Behavioral Activation Tip appeared first on Beck Institute for Cognitive Behavior Therapy.

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